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Health Care Reform Via Focus Group

The most recent issue of Health Affairs focuses on “The Politics of Health Care Reform” and features an article by pollster Celinda Lake, president of Lake Research Partners in Washington.

Lake takes the pulse of public opinion by holding focus groups, and then tries to shape a reform plan that mirrors their hopes and fears. Rather than crafting a blueprint for health care reform and then presenting it to the public for discussion, Lake believes that reformers should begin “by exploring voters’ own perceptions and the core values that shape their views on health care…Leaving aside the base voters at opposite ends of the spectrum who were most strongly in favor of or opposed to universal health care,” she and her group “focused on the large clusters of swing voters whose support for health reform was more conditional. Through segmented focus groups and a national telephone survey in 2006, we identified a set of values that drive these swing voters’ perceptions of reform.”

Lake has little patience with old-fashioned reformers: “Advocates for change in health care would like to think that by using a combination of facts and reason, they could persuade Americans that a progressive, universal health care system would be more effective, efficient, and humane than the current system,” she writes. But that’s simply not true, she asserts: “real changes must be enacted in the world of politics and public opinion, where values and perceptions are more important than facts and reason.”

Lake is not alone. I have heard other progressives express their belief that conservatives have “won” the national political debate in recent years because they are so clever at using memorable memes and slogans to appeal to voters’ values and emotions. And Lake is right that slogans don’t appeal to “fact and reason.” Slogans are like television ads or bumper stickers: they’re not designed to provoke thought; the goal is to make the mind click shut like a box.

As Lake goes on to describe the “perceptions” that reformers should
appeal to, it becomes apparent that those perceptions are often simply
wrong.

For example, she points out, voters really don’t understand what drives
health care spending: “Although their understanding of cost drivers is
usually muddled (far overestimating the importance of malpractice
lawsuits, for example), the desire to get costs under control is the
most powerful impetus for change. Americans believe that choice and
competition help control costs, so including these elements in reform
is important.”

As Lake knows, malpractice lawsuits are not the main driver behind
rising health care costs. Ever-more expensive medical technology is
pushing prices skyward. She also knows that choice and competition have
not brought health care prices down for the past 50 years, and it’s not
likely that they will in the future. When a rival comes to market with
a new pill, device or procedure it is rarely less expensive than the
treatment it is replacing.

But while acknowledging that Americans are “muddled,” Lake doesn’t seem
inclined to try to open their eyes. Instead, she counsels: use their
confusion to sell them on your plan. That’s why you should never
mention what’s going on in foreign countries: “An American solution is
needed,” Lake explains: “Most Americans are not looking to emulate
Canada or Germany but want a solution that uses American ingenuity to
deliver high-quality, affordable care to all. Many voters believe that
the United States has the ‘best’ health care in the world and are
nervous about changes that might dilute its quality.”

Of course stacks of medical research tell us that we don’t have the
best health care in the world. And if we expand on the system we have
now, we’ll just wind up with a bigger, more expensive mess. Structural
reform is needed. One might want to share that truth with taxpayers.
But explaining that would require appealing to “fact and reason”—which
are prohibited in Lake’s world.

Lake is not interested in explaining reform; her goal is to market
reform. And how do you market a product? By appealing to prejudices,
and playing on the ignorance of your audience. If they think a yellow
box make it a friendlier product, then put it in a yellow box.

But it’s not just the public’s “perceptions” that are important. You
must appeal to American “values.” Here Lake is blunt. “What Americans
want to know is: ‘what’s in it for me?’. “They want to know the bottom
line for themselves and their families: Will this plan make my care
better or worse? Will my costs go up or down? By how much?” After all,
she reminds reformers, “Since more than 90 percent of those who
actually vote still have health coverage, this becomes a comparison of
‘what I have now’ to ‘what I might get.’”

To be fair, Lake says that Americans also care about “responsibility,”
“choice” and “peace of mind.” But she has a disturbing way of assuming
that Lou Dobbs lurks somewhere in the heart of every American. “The
wild card in the health care debate in 2008 is immigration,” Lake
warns. “The continued influx of undocumented immigrants and the federal
government’s failure to manage the immigration system have generated
widespread resentment and frustration. Because voters widely perceive
undocumented immigrants to be a major burden on social services,
including the health care system, their instinctive reactions around
this issue are restrictive and punitive. This presents a dilemma for
advocates and candidates who are serious about achieving affordable
health care for all—knowing that any inclusive proposal will be
attacked as "providing health care benefits for illegal immigrants." In
the current environment, this is potentially a greater vulnerability
than any of the usual attacks on taxes, government control, and so on.”

And this, I have been told, is a reason why reformers should avoid the
phrase “universal healthcare.” It’s too inclusive. It suggests we might
extend healthcare to immigrant children.

Of course, as Niko has pointed out here on Health Beat,
the truth is that illegal immigrants do not present a major burden for
our health care system: “According to a 2006 RAND study, in 2000 health
care for undocumented immigrants between 18 and 64 years old cost
taxpayers about $11 per household—roughly the price of a cheeseburger
in Manhattan.” That’s $11 for an entire year of care. By sharing this
piece of information with the public, we might allay voters’ fears.

Or even better, why not appeal to the public’s more generous emotions?
Yes, most people worry first about themselves and their families, but
most also have enough imagination to fee empathy and to recognize that
“There but for fortune…” Few would want a sick child to go without
healthcare even if her parents had come here illegally.

True political leadership inspires and educates. It makes us feel that we, and the nation, can be better than we are today.

Finally, I can only wonder: what would have happened to civil rights
legislation if, instead of marching, reformers had said “let’s form a
focus group, and find out what the folks sitting on the fence in
Mississippi think”?

30 thoughts on “Health Care Reform Via Focus Group”

I think this is the most disappointing thing I’ve ever seen you write, Maggie.
I am disturbed as anyone else at how sourly and irrationally so many people hate immigrants, but if you go out and talk to ordinary people it’s a real problem. Celinda Lake deserves credit, not scorn, for identifying this problem and urging those of us who want reform to face up to it.
Emotion and fear are powerful forces in our politics. It would be dumb to ignore how they affect how people think about health care.
Your post comes across as sneering and arrogant. Frankly, although I agree with you on the merits and the facts, it’s so off-putting that I have a hard time seeing why I’d want to follow your lead in the coming fight for reform.
Paying attention to what average people think is not selling out.

Dan–
I’m sorry you were offended.
But my point is that illegal immigrants are Not a big burden on our health care system. By law, we only give them emergency care to prevent them from dying–no more. That’s why they cost us so little.
It seems to me that it would make sense to explain this to people so that they wouldn’t worry that national health reform would mean huge tax
increases to cover illegal immigrants. It wouldn’t.
You write: “Emotion and fear are powerful forces in our politics. It would be dumb to ignore how they affect how people think about health care”
I agree–but I think that means that you calm fears by offering facts, and that you appeal to people’s best, most generous emotions. .
To do otherwise is to assume that they are not capable of understanding the facts and lack the empathy to look beyond “what’s in it for me.”
. Celinda seems to me condescending in her assumption that ordinary Amercans can’t respond to facts and reasons, and only think in terms of “what’s in it for me.”
In this case,it’s not hard to explain the facts and, in any case, I think policy-makers and reformers should always tell the public the truth.
I also personally think that any sick child should get the full care he or she needs whether or not the parents came here illegally. This was not the
child’s choice.

If winning these policy debates was as simple as laying out the facts and expecting the more efficient, more fair, and more effective system to win out, we never would have set up this pathetic “system” in the first place. You know that. I know that.
But as we both also know that not much progress on this front has been made in over a generation — since Medicare and Medicaid in 1965. And it’s not because our side hasn’t had good data and factual arguments explaining why we’re right. It’s because we’ve failed to understand what people like about the current system — as crazy as we think they may be — and what they fear about change — as eager as we are to embrace that change.
I believe that we can appeal to both rational and emotional ideals that ordinary people hold dear in order to win universal care. I don’t care what we call it. Celinda Lake’s research will make that easier to do, not harder.

“She also knows that choice and competition have not brought health care prices down for the past 50 years, and it’s not likely that they will in the future.”
I think this depends a lot on what you mean by “choice and competition.” For example, suppose we had robust price and quality transparency that could help both patients and referring doctors easily determine which specialists, labs, imaging centers, drugs and hospitals offer the best combination of cost and quality. Unbiased, objective infomediaries akin to Consumer Reports would also be enormously helpful, at least for care that does not need to be delivered under emergency conditions.
Suppose people had a choice and could easily see the difference in premium between a high deductible plan and a low deductible insurance plan, or plans that offered a mechanism like health courts or arbitration to settle medical disputes vs. plans that used the current malpractice system, or plans that provided for a default protocol of palliative or hospice care if doctors determined that life expectancy is less than six months vs. plans that would pay to “do everything” if that’s what the patient wants.
As a practical matter, just because we don’t have a single payer system today, does not mean we have lots of “choice” as that term generally applies to a properly functioning marketplace primarily because of the absence of good price and quality information but also because of the inability to make other fundamental choices as described above.

Dan–
You write: “not much progress on this front has been made in over a generation —- since Medicare and Medicaid in 1965. And it’s not because our side hasn’t had good data and factual arguments explaining why we’re right. It’s because we’ve failed to understand what people like about the current system — as crazy as we think they may be — ”
This is all true. But I think we haven’t made progress since the mid 60s, not because the majority of Americans have become increasingly happy with our health care system, but because the wealthiest 20 percent or 30 percent have become more powerful (while their incomes and benefits rose.)
Keep in mind that 15 percent of “better -paid Americans” (who earn over $60,000 joint) and have employer-based insurance pay nothing toward their healtt insurance premiums. Their employer pays 100 percent.
These are “the people” who as you point out, “like the current system.”
But I think that most of these beter-paid Americans, like most Americans, have generous instincts, and reformers need to appeal to their better side, rather than pandering to their most selfish instincts.
Meawhile, I would suggest, the real middle-class (those who earn 10 percent more than or 10 percent less than median income–i.e. households earning roughly $41,000 to $52,000 joint household income) have become both less and less powerful and less and less satisfied with the current system.
If they are relatively young and healthy, they may not realize that the system is broken. But this is what heatlh care reformers need to tell them.

Nice work. What would have happened to civil rights legislation indeed? Well, enactment of it, as LBJ predicted, basically removed Democrats from power for decades. He was willing to pay that price. On the other hand, civil rights included a moral message. Clearly there was a legacy of discrimination against blacks, punctuated by violence in the South (Selma) and north (urban riots) that demanded redress. Those who lack health insurance now don’t have a similar moral claim. and one could argue that few political leaders today have LBJ’s courage. Also, remedies here are much tougher and less obvious. Programatically, it is much easier to give all the vote than to make health coverage universal.

Good post, Maggie…again. Did you get your red scrubs yet?
All valid points, but the mountain sure gets higher every single day. I was listening to Glenn Beck..a week or so a go, man, that guy is scary, he was ranting about how illegal immigrants are the reason our healthcare is so expensive, and words to that effect…I shushed everybody in the car and kept waiting and waiting for them to give the 800 number, I thought it was a call in show, it’s not. Lisa muzzled again and this guy and/or his producers clearly did zero research. This is the type of crap most Americans hear and believe because they heard it on CNN. How about McCain on the O’Reilly Factor…again a week or so ago, McCain said, and this is a direct quote regarding healthcare “There’s nothing wrong with the quality” meaning the quality of healthcare in America. A Presidential candidate doesn’t think there’s anything wrong with healthcare quality in America. We have a long, long way to go.
Maggie, if you have a publicist you should try to get booked on Bill Maher, O’Reilly, Glenn Beck, etc make the rounds, I sure wish I could because you’re right, we have to educate people, but I’ve yet to see anybody like Maggie, or me, or any of the many dedicated, educated yet muzzled reformers on these same shows. It’s very frustrating.

Jim, Lisa, Dan of Kentucky, Barry–
Jim — You wrote “Those who lack health insurance now don’t have a similar moral claim. and one could argue that few political leaders today have LBJ’s courage. Also, remedies here are much tougher and less obvious. Programatically, it is much easier to give all the vote than to make health coverage universal.”
I agree that remedies here are much tougher and less obvious. On the other hand, we’re not battling the same hatred that civil rights reformers were battling. (And you’re right parts of the South never forgave the Democratic party for what LBJ did.)
There is hatred of illegal immigrants, but they make up a tiny percentage of the uninsured.
On the question of whether people have a “moral claim” to high quality healthcare, I think that they do. Without your health, you cannot pursue life, liberty or anything else.
We are the only developed country in the world that rations healthcare according to ability to pay . ..
Lisa– Thanks–
Of course people like me are not invited on shows like that . . . But someone is making a one-hour docoumentary of my book,”Money-Driven Medicine” that should be on one of the networks late this fall. (The producer made “Taxi to the Dark Side” which just won an academy award for best documentary, and he also made “The Smartest Guys in the Room” about Enron, so I’m hoping it will be good.)
It is very frustrating to hear things that you know are untrue repeated, over and over again, on television and radio. This is what Hitler understood about propaganda: say it often enough, and eventually people will believe you.
Barry–
Unfortunately, in the healthcare market “choice”
generally means that you are free to choose what you can afford. (or, more accurately, you are forced to choose what you can afford.)
If you earn a median income, you cannot afford the most comprehensive insurance that offers a good network of doctors and real protection against financial catastrophe. (To buy that in N.Y.–just for myself, costs $7,000 a year (just to cover me), with a $2,000 deductible, and I had to stay in network–or pay quite a bit more. How much more? It depended on what the out of network doctor chose to charge.)
This was the insurance
I had when I was writing the books–and it was “group insurance”–through the Author’s guild. If I hadn’t been an author and had to buy it on my own, it would have been more.
And if I hadn’t had good advances for the books, I couldn’t have afforded it–no matter how much information and trasparency I had.
Moreover, good policies are pretty transparent–at least in NY. On a good policy, there are no annual caps or life-time caps. There are no 20 percent co-pays. Co-pays are never a percentage, they are a flat amount.
In a good policy, there is a cap on how much you would ever pay out of pocket in a given year. A list of doctors who take the insurance is available on line, along with info about them. Word-of-mouth tells you whether friends have doctors they like in the network.
(When I talk about a “good policy” I am talking about a good policy for a middle-class person who cannot afford any open-ended exposure–someone who doesn’t have $100,000 or more in savings.)
But it all comes down to : can you afford the premium?
Why is insurance so expensive? Because heatlhcare is so expensive.
Why is that? Becausse drug-makers, device-makers, and specialists all set their own prices–with no push-back, no negotiation.
I’ve just written about this on TPM cafe here– a piece you might find interesting http://tpmcafe.talkingpointsmemo.com/2008/05/13/the_third_obstacle_to_health_c/#comments
Dan from Kentucky– thank you for sending me that piece by Judis. I know who he is–but for some reason, I couldn’t open the link. (I have a subscripton to TNR, but it just wouldn’t open . . )

Health care system is and always will be very emotional topic and it’s almost impossible to believe voters will be driven by logic and not by emotions. Here in Canada it’s discussed topic as well, but these waters are much calmer, when whole nation is inside the system…
Lorne

Lorne–
Indeed, waters are calmer in Canada–and not just on health care.
My daughter went to college in Montareal and whenever we flew Air Canada to visit her, I was so impressed how people just filed onto the plane and sat down. No jockeying over space to store carrying on baggage, no one standing in the aisle, holding things up.
Of course all cultures have their pluses and minuses, but I (and my daughter) were impressed by how civil Canadians are.

Maggie and others,
This is a long post but I hope it’s useful in clearing up what seem to me to be misconceptions.
I’m very concerned that there seem to be misinterpretations about things Celinda says in the HA article, possibly b/c you and others aren’t familiar with the fuller context for this research. Celinda’s research is part of a broader and much lengthier project called The Herndon Alliance started by single payer Medicare-for-All activists led by Bob Crittenden (a primary care doc in Seattle). FYI I’ve been participating in the Herndon Project peripherally for almost 3 years and trust the soundness of their premise and commitment to far-reaching reform. Sadly, it does seem that many people who aren’t more closely involved in the Herndon project don’t understand the work and where it’s coming from/where it aims to go and so misinterpret the research and project’s goals and tactics. Celinda’s research is not about creating barriers to reform it’s about UNDERSTANDING the potential barriers that are already there and then DEVELOPING TOOLS to work through those barriers to achieve far-reaching reform such as Medicare-for-All eventually.
I’d like to ask that you and others take a look at the below excerpts and the more detailed info on the Herndon Alliance website http://www.HerndonAlliance.org
Here’s what their homepage says:
“Healing America’s healthcare
Americans agree that enough is enough. The time for health care reform is now. That’s why Herndon Alliance is bringing everyone to the table. We’ve talked with Americans from left, right and center, listening to what they value and what they want from their health care system.
Our goal is simple. To help you and other advocates and policy leaders across the country broaden the base of support for health reform and make health care a reality for all.”
this is what it says under “Who we are”:
“The Herndon Alliance is a nationwide non-partisan coalition of more than 100 minority, faith, labor, advocacy, business, and healthcare provider organizations.
For too long others have divided Americans through fear, instead of uniting them through hope and the unmistakable fact that Americans, when called upon, can do whatever it takes to get the job done.
The Herndon Alliance is expanding the base of people supporting affordable healthcare for all, and increasing the breadth and depth of voices working and speaking out for healthcare reform.”
and here’s what Herndon says about their research and tools for building a national movement for reform:
“Our extensive public opinion research findings connect the health care debate with the deeply held beliefs and values of the American public. The overarching findings include:
* Health care reform can be successful IF we address the concerns of the American voter.
* Americans want change and overwhelmingly favor the concept of Guaranteed Quality Affordable Health Care for All,linking the uninsured, underinsured, and insured in their concerns about affordability.
* Choice, Control, Peace of Mind, are keys to being heard and need reinforcing.
*Cost, Quality, Big Government, Undocumented Immigrants, Small Business are potential barriers to reform and need to be addressed with strong messaging.”
—-
Tonight I was able to hear Amy and David Goodman talk at a local public forum in Jamaica Plain MA on their “Standing up to the Madness” book tour. I sincerely think the Herndon Project is all about providing health justice activists like me, you, Lisa, and so many others, more powerful tools to stand up to the madness of the U.S. health care system and build a winning movement that will finally achieve far-reaching lasting reform.

Ann–
I am sorry, but I have heard Celinda Lake speak and I know people who know her very, very well.
When I heard her speak, she said, very clearly, “Do not ask an American family to give up anything for another American family.”
This is directly opposed to everything I believe about the need for collective thinking and social solidarity.
Celinda Lake appeals to the fearful soccer Moms of this country, terrified, as one sububanite said to me recently at a party: “If Hillary or Obama is elected we won’t continue to get our tax breaks. They’ll give Our Money to the poor.”
I’m sorry to be so harsh in my judgment. I often agree with you about heatlhcare Ann, but what Celinda Lake represents is a kind of thinking that is very dangerous for this country. Let me put it this way: Bill Moyers has a piece on AlterNet today where he says “Yes, Virginia, there is class warfare in America.”
Lake is appealing to everything that is most selfish among too many ( but not all) affluent
Americans
When Lake told health care reformers “Never ask an American family to give up anything for another American family,”
her point was both that the upper-middle class does not want to pay more taxes–and they don’t want to give up any of the healthcare they’re getting now.
They don’t want to be told: “no, we’re not going to cover that medication or test or procedure because there is no evidence that it is medically effective and we cannot afford to provide health care for everyone if we continue to provide ineffective ,wasteful care for some.”
But this the truth. If we are going to have universal coverage–and provide high quality care to all Americans–upper-middle class and upper-class Americans are going to have to accept the fact that they cannot continue to demand every new product they see advertised on TV, every new test that their brother-in-law had; every procedure that a neighbor had.
(Of course they can have any of these things if they are willing to pay for them out of pocket. But they can’t expect taxpayers and others in society to cover them–while children and low-income people go without high quality care.)
Medicine in the U.S. needs to be based on medical evidence.
When people like Celinda Lake talk about “Choice” they usually mean that everyone should be free to choose what they can afford. When they talk about “Control,” they, like REgina Herzlinger, are saying that they, the
“Opinion-leaders” want to be in the driver’s seat fo the SUV.
I did go to the website, Ann, and here is what Bob Crittenden, the head of the organization, said in a recent speech:
“you’ll remember from the first round of [our] research people are deeply resentful about being told that America did not have the best healthcare in the world and, in fact, just absolutely pushed back on that. They were just absolutely going to reject anybody who would say that. And that was rooted in some core values that had nothing to do with healthcare. That it had to do with America’s place in
world and people’s sense of wanting American superiority and feeling that they were losing that on a variety of fronts.”
Let me make a couple of points here. First, anyone who is still talking about America’s “place in the world” its “exceptionalism” or it’s “superiority”–after the War in Iraq, after our torture of prisoners . . .well I find this very troubling jingoism.
This is the type of talk that led us into Iraq in the first place.
We are not superior to other peoples on this globe. Voters who want to cling to the idea that we are superior are not the people I want laying down the “values” that should shape health care reform.
Health care reform shoud be driven by “equaltiy” not “consumerism” (Crittenden keeps talking about how we’re a nation of “consumers”–as if this is a wonderful thing._)
Secondly–and this is more pertinent to health care reform–if you don’t explain to people that our health care is not the best in the word, then how do you explain the hazardous waste in the system, and that we are not going to continue to cover every over-priced, unnecessary treatement that comes down the pike??
When talking about what he calls “American Values” Crittenden made it clear that his ideas about “values” are based on what people who vote (i.e. concentrated in the upper half of the income ladder–and women in this group in particuarl–) have to say. And here’s what he tells us:
“We also found that people really try to judge whether everyone is deserving of healthcare. . . .. People really try to figure out if you’re deserving or not. And what we found is, this relates to the value of personal responsibility which was key value that we found in the first research, . . .. When we fight with people about that value of personal responsibility they fight us back pretty hard. Because personal responsibility is a core value for the public.”
Excuse me– some people “deserve” healthcare and others don’t “deserve” it? This reminds me of how Medicaid defines the “deserving poor.” Under Medicaid law in many states, you have to be married and have children to quality for Medicaid. Single gay men can’t qualify. This became a huge problem during the
AIDS crisis, leading to much suffering and many, many deaths.
I can easily imagine people in these focus groups saying that obese people might not “deserve” healthcare–or that they should pay more for it. Of course they don’t want to hear that obesity is, to a very large degree, connected with poverty.
They don’t want to hear that affluent Americans pay less in taxes than the citizens of every other developed country–and this is why we have such poverty.
They may think that people who don’t stop smoking dont’ “deserve” healthcare.
Do they know–or want to know– that half of the adult Americans who smoke are mentallty ill? (This according to research from the UC SF Smoking Cessation Clinic.)
Bob Crittenden sure isn’t going to tell them. He’s not going to argue with them. He’s going to tell them what they want to hear.
He thinks social policy in the U.S. should be based on what upper-middle class people who vote say they want for themlseves and their famlies, in “Focus Groups.”
In his speech, he admits,
“immigration was our least successful challenge in the sense that we still don’t really have a good answer on it. And when we looked at erosion in the plan, feelings about covering illegal immigrants was the one attitude that still predicted diminished support for universal healthcare.”
So, he says later, “no illegal immigrants in the plan.”
He also admits that some of the people in his focus groups don’t think LEGAL immigrants deserve heatlhcare. “Why don’t they become citizens?” they ask. Only citizens deserve healthcare.
As I said in my original post, if people like Crittenden and Lake had been involved in the movement for civil rights in the Sixties, they would have said “black children in the schools? No, our focus groups tell us that white mothers in Mississippi really don’t'want that. And if we try to argue them they justreally get offended.”
So no black kids in the schools. Too bad. We’d really like to have it come out otherwise. . .
In her talk, Celinda Lake also made the point that they don’t have Latino voters in their Focus Groups because “those aren’t the people who woudl respond favorably to “Harry & Louise” ads–the ads that insurance companies used to get white middle-class and upper-middle class Americans to reject Clinton’s heatlh care plan.
Those are the people Lake wants in her focus groups–people who would respond to Harry & Louise ads. She wants their “values” shaping what we should be saying about health care reform.

Maggie – You and I are on the same page in regards to what values we believe ought to shape health policymaking and to drive healthcare delivery in our country and in the wider global community. But I still think you’re misplacing some criticisms about the work of Celinda and Bob, and Herndon, and that this needs to be addressed due to the positive and powerful potential of their work.
From my attendance at many Herndon Alliance mtgs over the past 3 years and from speaking with the leaders of this project–Celinda, Bob, Richard Kirsch (Citizen Action), Diane Archer (OurFuture.org) many times over the years, I firmly believe that Celinda Lake and Bob Crittenden share the very same values of social solidarity and equality that you and I and so many others hold dear. I believe that all of us equally want to see those values operationalized in our public policies, including healthcare reform.
To realize these goals we’ve got to confront a discouraging but very real fact: the incredible imbalance of wealth in our struggle to make sweeping social change, including far-reaching health system reforms. Being so grotesquely out-resourced means that our side, “the good guys”, has to get very very slick and sophisticated at mobilizing our support across the widest possible demographic groups to build the political demand for far-reaching reform. And then we’ve got to be able to hold on to that support when the attacks come.
The Herndon Project “values research” isn’t about identifying the values and messaging that will be used to shape the actual reform policy, it is instead about identifying the values and subsequent messaging that will speak most effectively to certain demographic groups about the notion of the need for reform and what that reform should look like. The focus groups are to develop messaging, communication tools, and marketing tools to meet people across the country (including Kansas) where they’re at, whether we like where they’re at (e.g. I’ve got mine and don’t you try to take any of it, or those who are holding out hopes to be in that group) or not.
As you did in your comment to me, I, too, use the civil rights movement analogy a lot when I speak about healthcare reform. I encourage people to stand up for what is right–comprehensive health care guaranteed for all–and to demand real universal HC in the form of improved Medicare-for-All. I use the analogy of the civil rights movement by asking people to consider how it would seem if that movement had abandoned the core principle of equality and settled for “the more politically feasible approach” such as equal rights for only light-skinned blacks at first and then maybe we can get other skin tones to be afforded these rights later on… That’s how stark and disturbing it feels to me as a citizen, and a nurse, to live in this country where only certain groups of people have health care and other entire groups are consigned to live sicker lives and to die younger because they are left out of having this most fundamental right recognized and fulfilled. And b/c we bear wtness to this suffering on such an intimate and repeated basis (those of us who work with the not-rich), the fact that we do not have a movement in this country where every health care worker is clamoring, demanding, comprehensive health care that is funded equitably and guaranteed as a right for all is deeply, deeply disturbing.
When I do public speaking and guest lectures I implore anyone who will listen to not unwittingly buy into the defeatist thinking of “we can only get what they say is politically feasible” and the closely-related “well, at least this is something–it’s better than nothing” which is, again, more defeatist thinking. And in many cases the “something is better than nothing” really is not. Case in point being the MA Health Insurance Law that mandates the purchase of expensive private insurance policies or else pay a fine, and the “affordable” policies have such high deductibles, co-pays and “20% co-insurance” that many people will not be able to afford to even use the insurance they are being forced to buy!!! This MA law isn’t “better than nothing” it’s state-sanctioned extortion.
But I digress, back to the premise of the Herndon Project and the work of Celinda and Bob. I’m not saying that it’s a perfect concept or reform strategy but from my experience being an activist on this issue for 20 years, 15 of these years as a nurse, I do think that the concept of developing sophisticated messaging tools to move different demographics of people to support far-reaching health reforms and that will hold the support of these people/voters throughout a prolonged litany of aggressive well-funded attacks on reform is an excellent idea. The attacks on reform in the way of Harry and Louise type-ads are sure to come from AHIP and PHarma–with AHIP disguised as “Citizens for Better Health Care” or such other crapola.
I think perhaps you and I are talking at cross-purposes about this Herndon Project work, if that makes any sense. Yes, there are big problems in this country and with a lot more than just health care, and they share some common underlying causes having to do with deeply held values and how people act on those values, and our problems have to do with fears and how people act when their fears are stirred up (whether we like it or not, GW Bush did get a lot of votes both times around).
Maggie, it seems to me that you are inadvertently attributing the Herndon research results about social values to Celinda and Bob’s personally held values when they are absolutely not one and the same. You seem to be blending them together when they are, in fact, very separate and distinctly different.
In the Health Affairs article they are discussing the research project’s concept and the results of that research as it applies to various demographic groups’ social values and the development of messaging that incorporates those values. Celinda and Bob are merely the reporters of what currently exists in the hearts and minds of many of our fellow Americans. I know they’re also very distressed, the way you and I are, that this is the thinking that exists to such an extent out there (anti-immigrant, I’ve got mine and won’t share, etc) but we’ve got to face reality that this thinking does exist. We don’t have to and should not condone this thinking, and that’s where I have my greatest concerns about the Herndon work. One item in particular that troubles me a lot is Herndon’s acceptance and embrace of the “consumerist frame” for discussing HC and HC reform. In fact I wrote to Bob Crittenden just last week expressing these concerns after reading the HA article.
I’m not in any way interested in being a defender nor an apologist for Herndon nor anyone else; I’m in this fight keeping my eyes on the prize and my shoulder to wheel alongside anyone and everyone else who shows that they, too, are in this fight for the long haul and with sincere motivations. I’m not interested in judging anyone, either, for that matter, but as I’m sure you know there are many people, so-called “advocates” who end up selling out for the grant money and the prestige. The two (money and prestige) often go hand-in-hand; if you could only see the list of “advocacy” groups that are funded by the MA BCBS “Foundation” (it’s connected at the hip to BCBS Corporate) and by the state’s HMO’s and to what tune $$–it would make you sick. This flow of money is a big reason why our state is now saddled with fraud in the guise of health reform, also known as the MA Health Plan/Individual Mandate Law.
We need all the help we can get to fight the greedy bastards who want to keep healthcare a privilege instead of a right, to keep it a major profit-generating commodity instead of a public good, and I believe that Celinda and Bob are two individuals committed to this goal. That’s why they’re carrying out the work of Herndon–to provide new tools for talking to people of all stripes about the need for far-reaching reform that will resonate with them where they’re at.

In my prior comment perhaps I should have said “we need to be very smart and sophisticated” (rather than “our side, the good guys, has to get very very slick and sophisticated…”).
Although this issue of semantics does raise an important point: Why do we progressives feel the need to always (for the most part) behave so nice and polite that it borders on surrender before the fight even gets going…
Actually, that very issue of tactics, how rough we’re willing to play, is a major element within the Herndon Project work…
And why shouldn’t the good guys get to use some of the persuasive tactics including intentional manipulation to achieve our goals? Manipulation happens all the time and is not inherently evil, is it? If the ends are just (Improved Medicare-for-all) then are we progressives being irresponsible to NOT use strategic manipulation, particularly when lives are at risk?
There’s a gradient for manipulation, I suppose, but we’ve got to stop playing so nice in this protracted and lethal battle for a just and equitable healthcare system in the U.S.. We’ve got to ramp up now to be ready to use all tactics, including civil disobidience, come this June, this fall and beyond.
Please get involved in this struggle in whatever way suits you at:http://www.guaranteedhealthcare.org
orhttp://www.healthcare-now.org

Ann–
I believe that you and I are on the same page. (I know Diane Archer pretty well and she and I are essentially on the same page though we debate whether progressives really should be adopting the “marketing techniques” that conservatives use.
I think slogans and bumper stickers cause people to stop thinking. I think we need messages that are longer than 4 words–and that provoke thought.
I dislike a “consumerist” approach to health care. Patients aren’t consumers, and this is about something far more important than consumer goods. Rather than stressing Consumer “Choice” and Consumer “Control” I would
stress patients and doctors working together.
We need to put physicians who have No conflict of interset back in charge of medicine. Panels of unconflicted physicians should be making the decisions about where medicial reserach is focused, what we cover, and best practice guidelines.
Consumers are not in a position to make these decisoins. And for-profit companies should not be making these decisions (as they are today.) Nor should politicians be making these decisions. They didn’t go to med school and are not professional researchers.
After decisions about “best practice guidelines” and “what to cover” are made, individual doctors need to level with patients about uncertainties, side effects, etc., and give patients a chance to share in the decision-making about what is best for that individual patient based on his tolerance for risk, etc.
Going back to Crittenden and Celinda, I believe that they are distressed at what they seem to find in the minds and hearts of Americans.
But I think that a) they are talking to the wrong Americans and b) that they are surrendering without a fight.
By talking to the wrong Americans I mean they are talking to people who have time to go to focus groups.
Some of these people are probably suburbanite stay-at home “soccer moms.” Many are men and women with white collar jobs. Most, I would bet, live in households with joint gross income over $100,000.
They represent just 16 percent of the nation.
People who have the time to participate in focus groups don’t have two jobs. They are not single mothers. The majority are white.
So this is a small, skewed segment of society. It’s perfectly fine to find out what they think. But we don’t need all of them –or even 80 percent of them–to agree with health care reform in order to win on this issue. It’s true that they vote, but, again, households with joint income over $100,000 represent only 16 percent of the nation.
In my humble opinion, the mistake the Clinton administration made was to shift its focus from teh traditional Democratic base: blue collar, ethnically and racially diverse, median income (now around $49,000 joint household income) union, etc. to upper middle class ($75,000 and above joint income) suburbanites.
In an effort to win that group (and in an effort to win back parts of the South), Clinton sponsored welfare “reform” that even someone like Robert Rubin realized was going to hurt poor women and children. And it has. (Rubin was strongly opposed to the legislation–and told me so.)
Clinton didn’t pick up on LBJ’s war on poverty and continue it. He allowed low-interest college loan programs for the upper-middle class to replace scholarships for the pooor based on financial need. He didn’t do much for inner-city and rural poor public schools.
It was, in short a centrist Democratic administration that tried to ignore the fact that poverty is the biggest problem in America.
Finally, I think Celinda and Crittenden are capitulating to a small group of Americans who are by and large, pretty well insured. There employer pays for most of their insurance. They want to keep what they have. They are afraid that if things improve for other people, they might lose something.
In many cases, one can get them to think more imaginatively by appealing to their better side.
In other cases, you can’t.
When you can’t, you say what LBJ said to white Democrats in the South who were against civil rights:
“Good-bye.”
Otherwise, we’re going to wind up with compromised health care reform that provides some sort of “insurance” for everyone–but not real health care. I see the Wyden bill as an enormous threat.

Ann–
I believe that you and I are on the same page. (I know Diane Archer pretty well and she and I are essentially on the same page though we debate whether progressives really should be adopting the “marketing techniques” that conservatives use.
I think slogans and bumper stickers cause people to stop thinking. I think we need messages that are longer than 4 words–and that provoke thought.
I dislike a “consumerist” approach to health care. Patients aren’t consumers, and this is about something far more important than consumer goods. Rather than stressing Consumer “Choice” and Consumer “Control” I would
stress patients and doctors working together.
We need to put physicians who have No conflict of interset back in charge of medicine. Panels of unconflicted physicians should be making the decisions about where medicial reserach is focused, what we cover, and best practice guidelines.
Consumers are not in a position to make these decisoins. And for-profit companies should not be making these decisions (as they are today.) Nor should politicians be making these decisions. They didn’t go to med school and are not professional researchers.
After decisions about “best practice guidelines” and “what to cover” are made, individual doctors need to level with patients about uncertainties, side effects, etc., and give patients a chance to share in the decision-making about what is best for that individual patient based on his tolerance for risk, etc.
Going back to Crittenden and Celinda, I believe that they are distressed at what they seem to find in the minds and hearts of Americans.
But I think that a) they are talking to the wrong Americans and b) that they are surrendering without a fight.
By talking to the wrong Americans I mean they are talking to people who have time to go to focus groups.
Some of these people are probably suburbanite stay-at home “soccer moms.” Many are men and women with white collar jobs. Most, I would bet, live in households with joint gross income over $100,000.
They represent just 16 percent of the nation.
People who have the time to participate in focus groups don’t have two jobs. They are not single mothers. The majority are white.
So this is a small, skewed segment of society. It’s perfectly fine to find out what they think. But we don’t need all of them –or even 80 percent of them–to agree with health care reform in order to win on this issue. It’s true that they vote, but, again, households with joint income over $100,000 represent only 16 percent of the nation.
In my humble opinion, the mistake the Clinton administration made was to shift its focus from teh traditional Democratic base: blue collar, ethnically and racially diverse, median income (now around $49,000 joint household income) union, etc. to upper middle class ($75,000 and above joint income) suburbanites.
In an effort to win that group (and in an effort to win back parts of the South), Clinton sponsored welfare “reform” that even someone like Robert Rubin realized was going to hurt poor women and children. And it has. (Rubin was strongly opposed to the legislation–and told me so.)
Clinton didn’t pick up on LBJ’s war on poverty and continue it. He allowed low-interest college loan programs for the upper-middle class to replace scholarships for the pooor based on financial need. He didn’t do much for inner-city and rural poor public schools.
It was, in short a centrist Democratic administration that tried to ignore the fact that poverty is the biggest problem in America.
Finally, I think Celinda and Crittenden are capitulating to a small group of Americans who are by and large, pretty well insured. There employer pays for most of their insurance. They want to keep what they have. They are afraid that if things improve for other people, they might lose something.
In many cases, one can get them to think more imaginatively by appealing to their better side.
In other cases, you can’t.
When you can’t, you say what LBJ said to white Democrats in the South who were against civil rights:
“Good-bye.”
Otherwise, we’re going to wind up with compromised health care reform that provides some sort of “insurance” for everyone–but not real health care. I see the Wyden bill as an enormous threat.

“Panels of unconflicted physicians should be making the decisions about where medical research is focused, what we cover, and best practice guidelines.”
With regard to the development of best practice guidelines, assuming we assign this role to a Comparative Effectiveness Institute or similar body, it will be a challenge to insulate its work and its decisions from both the industry and Congress. I would also not be surprised to see a lot of pushback from doctors, especially those who work solo or in small group practices, who don’t want ANYONE, including other doctors, telling them how to practice medicine or trying to hold them accountable for results, including cost-effective practice patterns.
While all the doctors who comment on this blog may be wonderful people who have only the best interests of their patients at heart, there are, in fact, many who own expensive equipment or have a financial interest in imaging centers or ASC’s who then utilize that equipment far more often than similar doctors who don’t have ownership interests in such facilities. Mckinsey, for example, estimates that doctors with a financial interest in expensive equipment order up to eight times as many studies per thousand patients than doctors in the same specialty that have to refer patients out to independent facilities.
The AMA, for its part, has a decades long history of trying to stifle competition at every turn. Most recently, it is opposing the spread of retail clinics staffed by NP’s and PA’s. Yet, at a panel discussion I attended at the University of Pennsylvania last weekend sponsored by the U of P’s School of Nursing, one of the experts who grew up in Copenhagen, Denmark said that NP’s here have as much education as primary care doctors in Denmark and can easily provide up to 85% of all primary care as well as a doctor can.
Instead of just bashing insurance companies and drug and device manufacturers, I think it’s time that doctors looked in the mirror and admit that they (who drive over 85% of all healthcare utilization) are a huge part of the problem. What are they prepared to give up in money or power in the short term in exchange for a better, more cost-effective healthcare system in the long term? Much of the time, their attitude comes across, at least to me, as: leave us alone to practice as we see fit, pay us our fees promptly, don’t hold us accountable, forget about P4P, and we’re not interested in price and quality transparency either. Sorry docs, but you’re going to have to do a lot better than that.

Barry–
I have been wracking my brain trying to figure out how to insulate a “comparative effectiveness institute” from Congress and the lobbyists for a long time.
But I think that the head of bioethics at the NIH (Dr. Ezekiel Eamanuel, brother of political strategist Rahm Emanuel, has come up with a brilliant idea.
Think dedicated VAT tax that means the Institute doesn’t have to go to Congress for appropriations. I’m going to be writing about it soon.
It makes a lot of financial sense; I think you’ll like it.

Barry, I totally agree with you about the need to shine more light on physicians behaviors and to hold them much more accountable for their role as a “stakeholder” group that has INORDINATE INFLUENCE AND IMPACT on our health care system. Thank heavens the med. students (AMSA at AMSA.org) broke away from the AMA years ago and are providing good and essential leadership on this front.
This physician “community” behavior issue is yet one more area where we have mounds and mounds of data identifying the problem and providing elements of an effective solution, but moneyed interests are planted firmly in the way determined to obstruct that solution.
I do have this group in mind when thinking about the obstacles to reform, in addition to the more commonly identified insurance and drug co’s. It would be a challenge to mobilize the public to understand this, I believe, b/c the psychology of healthcare makes people want to trust and defend their doctors in contrast to a more willing (or nowadays an eagerness) to see insurance and drug co’s as sources of the problem and a willingness to take them our of the driver’s seat. My view is that we must achieve fundamental reforms in the payment and delivery system with improved Medicare-for-All and that when we have a more functional system with clear accountability tied in to the one-payor we will be much better positioned to enact standards of practice for the MD community.
The ego, turf, and desire for personal fortune-making are pervasive dynamics affecting the MD community. I agree that this is a huge and oft undiscussed set of dynamics that must be addressed for fundamental reform to occur. So many of us know this to be true based on various experiences. I know it from working in the health care field as a nurse and from other life experiences r/t having 2 relatives with serious chronic illness (a sister dx’d w/schizophrenia 25 years ago and mother with epilepsy x 30 yrs). I also had a fascinating window on the self-interest of MDs when I condusted survey interviews in the ’80′s when I worked on the HCFA/Medicare RBRVS project to “realign” MD Medicare reimbursement rates.
It sure was telling to get such different reactions to the project itself and to some of the particular questions, whether it was a cardiac surgeon or neurologist versus a pediatrician or an internist I was attempting to get to complete the entire ~60 minute interview.
So, yes, there are large numbers of MDs who are, sadly, a part of the problem and are likely not to step forward to be a part of the solution. That must be tackeled head-on. Alan Sager and Debbie Socolar’s work at http://www.HealthReformProgram.org are doing important work to bring these facts forward and inject them into the reform debate. I look forward to reading more about Maggie’s ideas on this.
In the meantime there are large numbers of MDs who do want to be part of reforming the system and are willing to tackle these issues forthrightly. PNHP might be the place where the largest concentration of these docs can be found, but PNHP might not, as an organization, think it wise to take this MD Practice Standards issue on simultaneously with the fight for reform of the payment and coverage system in the way of improved Medicare-for-All that’s needed to guarantee affordable comprehensive care to everyone as a human right. For more on their work visit http://www.PNHP.org

Ann–
You write that
“The ego, turf, and desire for personal fortune-making are pervasive dynamics affecting the MD community.”
I agree that this is a “huge and oft undiscussed set of dynamics”
But let me add that I thinkthis is much less of a problem among doctors who who practice cognitive medicine–and generally much less of a problem among a younger generation of physicians.
Since the early 1990s, it has been pretty clear to people entering medical school that medicine was no longer going to be a clear route to making a fortune. Or, put it this way, it was clear that there are much easier ways of making money –on Wall Street, in business, real estate or finance.
As a result, my impressions is that today’s generation of doctors are less likely to be money-driven than, say, someone who chose med school in 1980.
Today’s young doctors are also less interested in being entrepreneurial solo practioners, more interested in working on salary, having regular hours and a family life. (This is in part because so many of them are women.)
They seem, to me, less ego-driven then some in early generations of doctors, and more collaborative.
Many are strongly opposed to doctors taking money from anyone that might create the appearance of conflict of interest.
PNHP is not the only strong-hold for doctors who want health care reform.
Many reform-minded doctors have told me that PNHP is so strongly committed to single-payer as the “only way” that they have turned off many other doctors with a “my way or the highway” approach.
I recently met a doctor who heads up a group of 10,000 young doctors who had met with PNHP and basically were told “either you’re with us or against us.”
This group is an outgrowth of the no-free-lunch etc. groups that were run by med students some years ago. They share all of the values I’m talking about above and as they grow, I hope they’ll be in the vanguard of reform.

Maggie,
Thanks for your thoughts on the non-homogeneous physician dynamic in the U.S. health reform movement. I agree with just about everything you say and will chew on it for a while and share your thoughts with other activists. I assume that the 10,000-member “young doctors” group you refer to is AMSA http://www.amsa.org
Re PNHP’s single-mindedness about streamlined financing (aka single-payer) for improved medicare-for-all reform, I can understand PNHP’s rationale (I’m a long time PNHP member myself) for insisting on enacting a reform plan that’s constructed on common sense and a tried and tested American model (Medicare), and that would for the most part meet the health care needs of all peoples and communities.
I also appreciate the reasoning that it’s not the wisest organizing strategy to alienate people and organizations who, although they share common values and goals, might not see exactly eye to eye with you on the imperative to advocate for one solution and nothing else, although as I write that it does give me pause to wonder “why not stick to what you think is the best solution and urge all other activists to do the same?”
Doesn’t it really boil down to the following:
“Everybody In, Nobody Out” must be a uncompromising position for the reform movement, imho, or else we’ll find ourselves doing incrementalism into eternity. We’ll also find ourselves putting most of our energies into “preserving the safety net”, and that, in reality, seves to perpetuate enforced poverty upon a huge segment of our society. Believe me, I know the importance of addressing unmet health needs in the most timely manner but I also see that I’ve been part of the activist community on this health reform issue for 20 years now. And overall things have gotten worse! We’ve got to be much more militant in our demands–they’re reasonable demands!!!!!!
And please don’t be fooled by the spin of John McDonough of HCFA MA and that ilk of incrementalists that really should be described as the “If you can’t beat ‘em, join ‘em” crowd.
The rhetoric sounds good but it very dangerous: the following was rolled out in a congressional briefing recently with ppt slide headings such as “The Power of Incrementalism” and “Continuous Policy Improvement”. These headings describe mere policy tinkering that builds on a terribly broken and harmful system isn’t reform and it only serves to dig us deeper into the hole.
In many respects it’s this “incrementalist” thinking and policymaking that is responsible for perpetuating our country’s god-awful health care crisis mess for so many years…(Case in point: the MA individual mandate law that forces people to purchase private insurance is just one more sorry chapter of this inherently flawed approach.)

Television’s misrepresentations of cultures are not advantageous to our progressive society. Generation after generation continues the fight against discrimination and stereotyping; communities such as Gay and African Americans often lead this battle. However, their efforts tend to be taken for granted and overlooked by network television. Examples of this blatant stereotyping might include shows such as Will and Grace, Good Times, and Sanford and Son. Hopefully, the average person doesn’t feed into these stereotypical traits of the Gay and African American communities, but these shows surely don’t help the cause. Entertainment has a long way to go in order to catch up to a progressive America that is more interested in enlightened entertainment, than old clichéd story lines. Unfortunately, the CW network chooses not to take the direction that the rest of America is moving in. Now, they are taking aim at the payday loan industry with their new show “Easy Money,” premiering on Sunday, October 5. If this show should gain as much popularity as the previous mentioned, society may acquire a distorted view of a legitimate business model. The American people might even take on the idea that the heads of payday loan stores are “loan sharks,” which is what they are called in the Easy Money trailers. These thoughts could potentially lead to passing irrational measures such as Ohio’s HB 545, which would drive payday lenders out of the state and bring about devastating ramifications. This just goes to show that we shouldn’t rely on Hollywood to learn about the world around us.
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